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 Table of Contents  
REVIEW ARTICLE
Year : 2015  |  Volume : 15  |  Issue : 1  |  Page : 45-51

All-cause mortality among elderly patients admitted to the medical wards of hospitals in Africa: A systematic review


1 Chief Tony Anenih Geriatric Centre, University College Hospital, Ibadan, Nigeria
2 Department of Medicine, University College Hospital, Ibadan, Nigeria
3 Department of Medicine, Faculty of Health Sciences, The Albertina and Walter Sisulu Institute of Ageing in Africa, University of Cape Town, South Africa

Date of Web Publication10-Dec-2015

Correspondence Address:
L A Adebusoye
Chief Tony Anenih Geriatric Centre, University College Hospital, Ibadan
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1596-4078.171372

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  Abstract 

Geriatric medicine as a speciality is just evolving in Africa. There is scanty data on the mortality and associated factors among elderly patients admitted to the hospital medical wards in Africa. The objective of this review was to identify, describe, and analyze systematically the available studies on all-cause mortality and associated factors among elderly patients admitted to the medical wards of a hospital in Africa. Online and hand-based systematic searches were conducted for literature (primary and secondary) describing the mortality in elderly patients admitted to the medical wards of a hospital in Africa. These included original research, review articles, proceedings, and transactions from 1969 to 2014. All identified studies were screened using the Population, Intervention, Comparison, and Outcomes criteria. Five studies describing 3427 hospitalized elderly patients reported 773 deaths giving an unadjusted proportion of admissions which resulted in in-hospital deaths of 22.6% (range: 6.8–44.7%). This was higher among the males (38.8–48.0%) compared with the females (29.4–40.7%). There was no significant association between the age and mortality. Mortality was high among patients who had stroke, meningitis, septicaemia, renal failure, chronic liver disease, chronic obstructive pulmonary disease, severe asthma, and heart failure. High mortality was associated with high serum creatinine and urea, tachycardia, reduced length of stay from admission to death, and low serum protein. In conclusion, the few available data showed high unadjusted all-cause mortality among hospitalized elderly patients in Africa. More studies are needed in Africa to quantify this health burden and identify the major factors causing the high mortality in elderly patients.

Keywords: Africa, elderly patient, medical ward, mortality, systematic review


How to cite this article:
Adebusoye L A, Owolabi M O, Kalula S Z, Ogunniyi A. All-cause mortality among elderly patients admitted to the medical wards of hospitals in Africa: A systematic review. Niger J Health Sci 2015;15:45-51

How to cite this URL:
Adebusoye L A, Owolabi M O, Kalula S Z, Ogunniyi A. All-cause mortality among elderly patients admitted to the medical wards of hospitals in Africa: A systematic review. Niger J Health Sci [serial online] 2015 [cited 2019 Aug 19];15:45-51. Available from: http://www.chs-journal.com/text.asp?2015/15/1/45/171372


  Introduction Top


In-hospital admission and mortality of elderly patients is high globally and is increasing, especially in Africa. This increase is due to the increasing proportion of the elderly in many communities. The proportion of elderly people in Africa is lower (4%) than the proportion for the global population (8%) and the proportion in developed countries (17%).[1] Africa has the highest rate population growth with projections estimating that the continent will double her elderly population between 1998 and 2050 unlike the one-third growth in the elderly population projected for developed countries during the same period.[2],[32] Most countries in Africa are in the stage 2 of the demographic transition (falling death rate and high birth rate), resulting in increasing the proportion of the elderly people within an expanding population.[4]

Hospitalization for medical illnesses is considered to be a risk factor for death among elderly people, because it is associated with adverse effects including nosocomial infections, loss of independence and autonomy, disability, social isolation, and iatrogenic conditions.[5] Hospitalization results in progressive functional, physical, and cognitive decline of the normal aging process. Thus, most hospitalized elderly do not return to their previous functional level following hospitalization.[5]

The pattern of death among hospitalized elderly patients in Africa is poorly described. The global median life expectancy years after the age of 60 years increased from 17 years in 1990 to 19 years in 2009. The global median life expectancy years remained 15 years for the same period for elderly Africans.[6] Noncommunicable diseases (NCD) may account for the highest probability of deaths in Africa between 2010 and 2020.[7]

In most parts of Africa, the management plans of elderly patients vary widely within hospitals and various specialities. Elderly patients admitted in the hospital are often managed as general adult cases due to the nonavailability of standard protocol for managing elderly patients in the most of hospitals. There is also a dearth of geriatric physicians as geriatrics as a field of specialty is just evolving on the continent.[8] For example in 2013, South Africa had eight registered geriatric doctors serving a population of 4 million elderly people.[8]

Health seeking behavior of people in the most part of Africa is generally, with elderly patients presenting to the hospital late. This is mainly due to poverty [9],[32] and sociocultural norms which promotes poor healthcare seeking behaviors.[10],[32] There is also an implicit assumption on the part of the healthcare workers that little can be done to treat the ailments of the elderly patients.[9],[32] The elderly and their relations often see hospitalization as a transit to death,[10] thus many often decline hospital admission and often present late to the hospital.[9],[32] Unfortunately, this process sets of a vicious cycle that results in elderlies who present to the hospital getting hospitalized and hospitalized persons dying. The vicious cycle continues to reinforce the notion that hospitalization of the elderly results in death. The high mortality associated with the hospitalization of elderlies may be stemmed if healthcare workers are trained on how to manage elderly patients.

The aim of this review was to describe the causes of mortality among elderly patients admitted to the medical wards of hospitals in Africa. It conducts a systematic review of epidemiological studies that assessed admissions of elderly persons in the general and acute care medical wards, and identifies the prevalence of mortality and causes of deaths while on admission.


  Methodology Top


Literature search

PubMed, Medline, EMBASE, African Journal Online, and African Index Medicus were searched for studies describing the mortality among elderly patients admitted to the hospital medical wards in Africa. The search items were "mortality" or "death," "hospital" or "admission," "elderly" or "older," "medical," and "Africa," We conducted this search on 1st and 2nd of September 2014. We included studies written in English and French languages.

All the 4842 abstracts of studies found were screened to identify the relevant studies, which met the specific inclusion criteria by having the combinations of the search items. This yielded 14 studies, which were later subjected to further screening using the Participants, Intervention, Comparison, and Outcomes (PICO) criteria.[12] Five studies are meeting the inclusion criteria. The nine studies excluded by PICO criteria were those which had no extractable data on the proportion of elderly patients on admissions which resulted in mortality, and those which had figures on mortality cases in adult patients admitted to the medical wards but did not have extractable data on elderly patients. In addition, we reviewed the references cited in these studies to find other studies that could be relevant. We included additional two studies which did not meet the PICO criteria for the primary review but have extractable data for the sub-analysis to enable us conduct secondary review of the factors associated with mortality among elderly patients admitted to the medical wards of hospitals.

Search strategy

We used the PICO worksheet and search strategy. We define our question using the PICO criteria. We include studies where study participants were persons aged 60 years and above. The intervention was defined as admission to medical wards of hospitals and the outcome was mortality. There was no need for comparison for this study. The search included all publications that were systematic reviews, case–control study, case series, case reports, and cohort studies.[12],[32]


  Results Top


The flow chat for the online and manual search is shown in [Figure 1]. Of the five studies, which met the PICO inclusion criteria, one was written in French language.[14]
Figure 1: The flow chart for the study selection using the Participants, Intervention, Comparison and Outcomes criteria.

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[Table I] shows the studies from which data were extracted using the PICO criteria. This was translated to English language by one of the authors. Three of the studies were from West Africa,[14],[15],[16] one was from North Africa [17] and one was from East Africa.[18]
Table I: Data extraction using the PICO criteria

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The nine studies [19],[20],[21],[22],[23],[24],[25],[26] excluded in the primary review are shown in [Table II]. The total number of hospitalized elderly patients from the included studies was 3427. The number of deaths was 773. The unadjusted proportion of admissions which resulted in all-cause mortality was 22.6% (range: 6.8–44.7%). The highest proportion of mortality (42.8–44.7%) was in the elderly hospitalized for acute illnesses in the medical intensive care wards, followed by those hospitalized at the tertiary care level (31.7%).
Table II: Studies excluded from the review

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Two studies [15],[32] reported the sex differences among 527 elderly patients studied. There were 149 deaths among 341 hospitalized elderly males and 63 deaths among the 186 hospitalized females. The mortality was higher among the males (38.8–48.0%) compared with the females (29.4–40.7%). Unadjusted risk ratio = 1.20, 95% confidence interval = 0.51–1.19 [Figure 2].
Figure 2: Mortality rates by sex.

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One study [17] found no significant difference between the ages of the hospitalized elderly and the outcomes (mortality vs. survival = 71.7 years vs. 71.7 years).

We tabulated the diagnoses according to the International Classification of Primary Care diseases classification.[27] Three (60.0%)[16],[18],[19] out of the five studies that met the inclusion criteria and two additional studies [21],[32] reported the mortality among different disease conditions diagnosed in the hospitalized older patients. Mortality among hospitalized elderly patients with stroke ranged between 19.8% and 52.8%. Mortality varied widely among patients who had meningitis (3–66.7%), septicemia (2.5–50.0%), renal failure (3.8–57.1%), chronic liver disease (1.8–60.0%), chronic obstructive pulmonary disease (COPD) (3.9–57.1%), severe asthma (55.6%), and heart failure (6.2–60.9%) as shown in [Table III].
Table III: Mortality among cases

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Five studies [14],[15],[17],[19],[20] reported the average length of stay to either death or discharge. Two studies compared the length of stay between elderly patients who survived and those who died during hospitalization. Sanya et al.[15] reported the average length of stay of those survived hospitalization as 18.5 (4.1) days and those who died during hospitalization as 10.4 (8.8) days. Belayachi et al.[17] reported an average length of stay of 6.9 ± 4.9 days among survivors and 6.3 (7.3) days among those who died during hospitalization. Two studies [15],[32] reported on some laboratory results of the hospitalized elderly patients. Sanya et al.[15] reported significant higher values of mean serum sodium (136.1 vs. 134.3 mmol/L; P = 0.07), potassium (4.2 vs. 3.7 mmol/L; P < 0.0001), urea (10.5 vs. 6.8 mmol/L; P < 0.0001), and creatinine (187.2 vs. 122.8 µmol/L; P < 0.001) among those who died and those who survived hospitalization, respectively. The mean serum urea (>16.6 mmol/L) and creatinine (159 µmol/L) were found as the predictors of mortality by Belayachi et al.[17] The mean blood glucose level of elderly who died during hospitalization was 11.2 mmol/L, while it was 10.9 mmol/L in those who survived the hospitalization.[17]


  Discussion Top


We found five studies, which met the inclusion criteria for the primary review and two additional studies, which were used for the secondary review from four countries in Africa. The unadjusted all-cause mortality among elderly patients admitted to the medical wards of hospitals in this African series was of 22.6%. Highest mortality was reported among elderly hospitalized for acute illnesses in the medical intensive care wards. All-cause mortality was higher among the elderly male patients and there was no significant association between the age of the elderly patients and all-cause mortality. There were wide variations in the mortality reported by various authors among elderly patients who had stroke, meningitis, septicemia, renal failure, chronic liver disease, COPD, severe asthma, and heart failure. Laboratory predictors of mortality from all-causes among patients in the intensive care setting were high serum urea and creatinine.

The limitations of this review are principally the few studies published on the mortality among elderly patients in the medical wards of hospitals in Africa making meta-analysis of the data difficult. Thus, we could not employ the risk adjustment technique. In addition, all the studies found were retrospective studies in view of poor record keeping in Africa. Sociocultural practices such as low healthcare utilization (3.2–31.5%)[28],[32] delay in seeking health care, concealment of deaths of elderly within families and aversion for autopsy might have contributed to the few elderly patients in the hospitals and difficulty in ascertaining the definitive diagnoses. Special interests of authors for younger population also account for the few data on the elderly patients in the hospitals.

The unadjusted all-cause mortality among elderly patients admitted to medical wards of hospitals in this African series is high compared with studies in South America (16.4%), North America (8.2%) and Europe (5.0%).[30],[31],[32] Compared with young adults, there is a higher mortality among elderly patients in the hospital medical wards.[15],[16],[21] The most common factors associated with mortality among hospitalized elderly patients reported in studies were complications or acute exacerbation of chronic morbidities.[17] In this review, the leading causes of mortality were stroke, meningitis, septicemia, renal failure, chronic liver disease, COPD, severe asthma, and heart failure. This was similar to the mortality pattern seen among the Europeans, with the most common causes of mortality among hospitalized elderly patients being heart failure, chronic renal failure, and COPD.[33] However, in Asia, Nakajima et al. reported a mortality pattern led by neoplasm, pneumonia, cardiovascular disease, stroke, and renal failure among the older Japanese.[34] Naidoo reported that cardiovascular diseases, especially hypertension and diabetes mellitus accounted for most deaths in hospitalized elderly patients in South Africa.[35] In Nigeria, hypertensive heart failure (19%), stroke (12%), and tuberculosis (11%) were the leading causes of death among hospitalized elderly patients in Ilorin.[15] Cardiovascular disease (43.7%) was the leading cause of deaths among hospitalized elderly patients in Port-Harcourt Nigeria, followed by infection (18.8%) and endocrine problems (15.4%).[20]

The individual characteristics of age, gender and genetic constitution, which are termed nonmodifiable or immutable factors also impact on mortality among hospitalized elderly patients. Some studies reported advanced age to be significantly associated with this outcome.[30] However, no such association was not reported by Belayachi et al., among the Moroccan elderly patients during hospitalization.[17] Male sex has been found to be significantly associated with mortality.[30] This review showed higher mortality among elderly male patients compared with their female counterparts. Studies have shown that higher proportion of elderly admissions to the medical wards are males (69.8–74.6%).[15],[20],[21] The findings of significantly higher serum creatinine and urea among elderly patients who died while on admission in the medical ward may make a case for routine testing of these parameters within 24 h of admission.

Socioeconomic characteristics strongly influence the life-course of an individual and thus, the biological health of the individual. Long-terms interaction between societal social structure and an individual's life events (such as employment and occupation) produce patterns of cumulative advantages and disadvantages which affect the biological health and mortality of the individual in old age.[36] Being in the low socioeconomic class has been found to be related to poor access to healthcare services and adoption of unhealthy lifestyles such as tobacco smoking, excessive consumption of alcohol, and poor dietary habits which are also partially a consequence of adverse social conditions.[33],[32] None of the studies reviewed reported on the impact of socioeconomic factors on the mortality among elderly patients admitted to the hospital medical wards in Africa.


  Conclusion Top


This review has shown high all-cause mortality among elderly patients admitted to the medical wards of hospitals in Africa. The major morbidities causing mortality are acute episodes and/or complications of preventable chronic medical diseases which can be addressed in primary care settings and thus prevent hospitalization. Furthermore, this review has shown that studies giving insights into the medical causes of mortality among hospitalized elderly Africans are scarce despite the numerous healthcare challenges facing this fast-growing population sub-group in Africa. The future is for more research to be conducted in the field of geriatrics, especially in the clinical settings as Africa is witnessing a transition from infectious to NCD and an exponential growth in the elderly population.

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table I], [Table II], [Table III]


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